Overcoming Trichotillomania
by Dave Carbonell, PhD
Trichotillomania afflicts millions of people worldwide, and ten million in the U.S. The shame and secrecy that so many experience with this problem naturally makes it harder to solve. But it can be overcome.
About Trichotillomania
Trichotillomania is a compulsive pattern of pulling one's hair out, to the point where it results in noticeable hair loss. People afflicted with this typically experience a powerful sense of shame and embarrassment which leads them to try to hide their hair loss. This often results in the use of cosmetics, hats, and other devices to hide the hair loss, as well as the avoidance of activities which may reveal it, such as swimming, being outdoors in the wind, and physical intimacy.
It's believed to affect about 3% of the population, and occurs much more frequently among women. It usually appears in late childhood or adolescence. It's often accompanied by increased levels of anxiety and depression.
Factors Associated with Hair Pulling
The hair pulling in Trichotillomania is not a random activity, but typically follows a characteristic pattern. Identifying the specifics of your pattern is a key part of the recovery process.
Which Hairs are pulled
Trichotillomania can involve hair on any part of the body - head, face, genitals, and so on. Most individuals with Trichotillomania focus on one particular type of hair and favor that above the others. Individual characteristics of the target hairs, such as color, texture, and size can also be important. People sometimes have characteristic responses to their hair pulling - rubbing the hairs against their skin or lips, disposing (or saving) of the hair in a particular way, even swallowing the hair.
Where People do the Pulling
People usually pull hairs in relatively private places where they won't be observed, and are less likely to pull it in the presence of others. It's usually done in relatively sedentary activities, such as watching television and doing homework. It is also a frequent occurrence during solo activities which are not particularly demanding, such as driving a car or taking a shower.
Internal Cues
A variety of internal discomforts are often associated with compulsive hair pulling. These discomforts may trigger an individual episode of hair pulling. This includes emotional states, such as anxiety, tension, anger, boredom, and frustration. It includes physical sensations, such as muscular tension and vague feelings of "not feeling right". It may also include thoughts that identify a "defective" hair which needs to be plucked, because it seems too long, too light or dark, and so on.
Why Do People Pull Their Hair?
Hair pulling is often triggered by one or more of the internal discomforts described above. The hair pulling usually has the effect of reducing the discomfort, or replacing it with comfort. Some people report a sense of pleasure may accompany the hair pulling.
However, this isn't always the case. Some hair pulling seems to occur in the absence of any internal discomforts, when a person isn't particularly paying any conscious attention to their hair or their hands.
Treatment of Trichotillomania
Trichotillomania is not considered treatable by general psychotherapy, or psychoanalytic psychotherapy. The most effective method available is a combination of two cognitive behavioral strategies: Habit Reversal and Stimulus Control.
Habit Reversal
Habit Reversal consists of two components. The first is Awareness Training, in which you take the time to get some very specific observations of your hair pulling habit: when you do it, where you do it, which hand, which fingers, and so on. The most important outcome of this training is for you to develop a very good awareness of the early warning signs (internal and external) that you are about to start pulling. When you notice a warning sign, this serves as a signal for you to reply with the second part of Habit Reversal, an incompatible or competing response. Let's say, for example, that one of your warning signs was your right hand approaching your chin. You would use a competing response whenever you noticed your right hand coming up to your chin.
A competing response would be some action that makes it hard, or impossible, to pull your hair. For instance, you might make a fist, and put your hand in your lap, keeping it there for a few minutes until the moment passed.
Stimulus Control
In contrast to the Habit Reversal responses, which are used in a moment when pulling seems likely, Stimulus Control is focused on prevention in general. It aims to limit the number of times you pull by identifying and eliminating environmental cues which may trigger hair pulling or make it easier to do. Examples may include limiting the number of mirrors in your home, if mirrors serve as a cue for you, or perhaps reducing the brightness of light in a room with a mirror, so you see less detail. It might include the addition of objects to a room, as in the example of having a paperweight handy in your television room, so that you can hold it while watching television. With Stimulus Control, you aim to reduce the presence of environmental cues which favor hair pulling, and increase the presence of those which make it less likely.
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Last updated on October 30, 2024